Volume 53, Issue 2,
March 2011

This edition of the SAFP features five CPD articles, which I hope will add some new knowledge that may influence your practice. In the first, Lifestyle and obesity by EW Derman et al, obesity is defined as an excessive amount of body fat or adiposity, which is measured by the body mass index. There is ample evidence that obesity is clinically associated with a variety of chronic diseases and medical conditions, such as coronary artery disease. The authors stress that obesity is a global phenomenon and that, in South Africa, an estimated 29% of adult men and 56% of adult women are overweight or obese.

Obesity is defined as an excessive amount of body fat or adiposity. It can be measured using the body mass index (BMI), and according to established criteria for adult men and women, overweight is defined as a BMI between 25-30 kg/m2, and obesity as a BMI > 30 kg/m2. Obesity is clinically associated with many serious co-morbidities, and is widely recognised as one of the leading health threats in most countries around the world. Weight loss is recommended for patients with a BMI > 25 kg/m2. The goals of weight loss therapy are to reduce obesity-related co-morbidities and decrease the risk of future obesity-related medical complications. The management of obesity is multifactorial, and involves the use of combined lifestyle interventions, including regular physical activity and dietary and psychosocial intervention. Practical clinical advice regarding interventions in these important areas is provided in this article.

Cardiovascular disease remains the leading cause of mortality in the Westernised world. Lifestyle changes and drug therapy can reduce cardiovascular risk. Many interventions such as lipid-lowering therapy reduce relative risk to the same extent irrespective of baseline risk, but the absolute benefit is still highest in those with the highest absolute risk. Cardiovascular risk assessment is a tool to determine absolute cardiovascular risk in asymptomatic patients and to select those most likely to benefit from intervention. Conventional risk assessment (Framingham) requires age, gender, blood pressure, smoking status, total cholesterol and high-density lipoprotein cholesterol (HDLC) to determine risk. This is usually expressed as the 10-year risk of coronary heart disease. The accuracy and predictive ability of conventional risk assessment have limitations. Many biomarkers, genetic tests and vascular imaging procedures correlate statistically with vascular risk. Adding these tests to conventional risk assessment (expanded risk assessment) may therefore improve our ability to predict risk. It has, however, been difficult to conclusively demonstrate that expanded risk assessment outperforms conventional risk assessment. Many tests and procedures require further validation before they become part of routine clinical practice. Additional testing may be useful in patients with intermediate risk or where risk is difficult to determine for other reasons.

Attention-deficit hyperactivity disorder (ADHD) has an estimated prevalence of 3.5% in adults. Knowledge regarding the diagnosis and treatment of this condition remains limited amongst general practitioners. The clinical presentation is highly variable, and the manifestations of the characteristic symptoms of inattention, hyperactivity and impulsivity are different in adults. Furthermore, there is a high incidence of comorbidity. At present, no definitive criteria are available for making the diagnosis. Several rating scales are available, but the diagnosis is essentially a clinical one, and can often only be made with the help of a psychiatrist. Essential features include the presence of ADHD in childhood and significant functional impairment as an adult. Core ADHD symptoms do not always form part of the presenting clinical picture, and awareness of some of the more common initial complaints is important. Stimulants have been shown to be an effective treatment for this condition in both children and adults. ADHD is a rapidly evolving field, and the optimum tools for diagnosis and treatment are not yet available. A functional knowledge of this condition is essential for the general practitioner.

In South Africa, the general practitioner is often the first health professional to provide care and health advice to pregnant women. Estimation of blood pressure levels is an essential basic step, particularly in pregnant women. Hypertensive disorders occur frequently in pregnancy and are significant causes of maternal morbidity and mortality. General practitioners should be aware of the complications associated with hypertension and recognise that severe hypertension requires prompt, gradual and sustained lowering of blood pressure, intensive counselling and early referral to an appropriate hospital.

Superficial bacterial infections of the skin are very common. With the increasing burden of human immunodeficiency virus (HIV), this is likely to worsen. Examples of such infections include impetigo, erysipelas, cellulitis, ecthyma, furuncles, carbuncles and subcutaneous abscesses. Common causative organisms are staphylococci and streptococci. Generally, Staphylococcus aureus infections tend to spread locally, causing abscesses and carbuncles, while streptococci are apt to spread along tissue planes, and give rise to either cellulitis or erysipelas. However, this is not always the case. These infections cause a significant morbidity, and have to be diagnosed and treated promptly. Some result in serious complications.

This groundbreaking textbook provides a concise yet substantial update on the South African primary care context, while drawing on the latest international research and the global clinical knowledge base to substantially revise the clinical nurse practitioner's skill set. "Competent primary care providers who 'put people first' are required in the front line in order to make a difference. The need for widely accessible, competent and caring clinical nurse practitioners" (Mash et al, 2010: xii) prompted the compilation of this outstanding text. Hitherto, community and primary care nurse training tended to be limited to a narrow framework of biomedical formulas relating, primarily to the physical body. By contrast, this first edition of the South African Clinical Nurse Practitioner's Manual presents a holistic continuum marked by a refreshing approach.

In October 1989, the much-publicised Human Genome Project was initiated. The main aims of the project were to chart the complete human genome by determining the sequences of the three billion chemical base pairs that make up human DNA and identify all genes in human DNA. This critical information would be stored in databases readily available to researchers, and the tools for analysing such data would be improved in order to facilitate and develop further research in the field of genetics. Key technology developed through this United States Federal Government-funded project would also be licensed to the private sector in order to kick-start genetics-related industries.

Most adverse health effects of cigarette smoking are attributed to the products of combustion. Efforts to avoid the adverse health effects of cigarette smoking have led to the promotion of alternative products that are perceived to be less harmful. In this paper, we review the available literature for evidence of the effectiveness of the products commonly presented as alternatives to cigarette smoking, and discuss evidence-based information on whether they should be promoted as safe alternatives for long-term use or are effective as cessation aid. Water pipe smoking is becoming prevalent among young people and the electronic cigarette has been recently introduced as smoking alternative in smoke-free areas. Available limited data suggest that while smokers may perceive these alternatives as safer than cigarette smoking, they contain toxic substances and therefore are not harmless alternatives.

Data on herbal products are not easily available and where they are, evidence shows that these products are also not effective alternatives. Smokeless tobacco products vary in composition and health effects worldwide. The available literature suggests that these products may be associated with adverse health outcomes and that they cannot be promoted as 'safe' alternative tobacco products. Nicotine replacement therapy (NRT) formulations, such as chewing gums and skin patches, have been well studied and evidence suggests that all forms are effective smoking cessation aids, either used alone and in combination with other NRT or cessation medication and behavioural therapy. Primary care physicians should therefore only offer NRT to smokers who are willing to quit in combination with behavioural therapy or other cessation medications approved by the South African Medicines Control Council.

Background: The aim of this study was to determine the prevalence, age, sex distribution and blood pressure (BP) pattern of patients with orthostatic hypertension in a cohort of hypertensives.

Method: A total of 179 patients on follow-up treatment in a hypertension clinic were assessed for age, sex and BP in the seated position, and after two minutes in the erect position, on three consecutive visits. Orthostatic hypertension was defined as an increase in systolic blood pressure (SBP) of ≥ 20 mmHg on more than one occasion in the erect position. Orthostatic hypotension was defined as a decrease in BP on more than one occasion, between the seated and erect SBP, of ≥ 20 mmHg. The mean ages of the participants with and without orthostatic hypertension were compared by t-test for any significant difference. The means of the seated SBP of participants with and without orthostatic hypertension were also compared with the t-test. The effect of gender on orthostatic hypertension was tested with a chi-square (X2). The differences between the mean seated and mean erect SBPs of participants with and without orthostatic hypertension were compared with the paired t-test.
Results: Thirty-eight (21.23%) of the participants had orthostatic hypertension. The mean age of those with orthostatic hypertension was not significantly different from that of the participants without orthostatic hypertension (p-value = 0.789). There was no significant effect of gender on orthostatic hypertension (p-value = 0.795). The mean of the seated SBP was significantly lower in the participants with orthostatic hypertension (p-value = 0.008). The mean seated SBP was significantly different from the mean erect SBP for those with orthostatic hypertension, compared to those without orthostatic hypertension (p-value = 0.000 vs. p-value = 0.169). Five (2.79%) of the participants had orthostatic hypotension.
Conclusion: Orthostatic hypertension, a form of BP dysregulation, may be more common among treated hypertensives than what is presently known.

Background: Migraine-associated vertigo (MV) remains a developing entity because accepted diagnostic criteria are unavailable. Patients present with debilitating dizziness without experiencing headache, and are often misdiagnosed as anxious. The condition is manageable in primary care without the need for neurological referral. The aim of this study was to investigate the prevalence of MV and migraine-associated dizziness (MD) as presenting complaints.

Methods: Patients presented with dizziness probably or definitely associated with migraine history based on the criteria of the International Headache Society. Patients with other vestibulopathies and medical conditions were excluded. Patients were evaluated over a period of nine months. Seven hundred and seventeen patients were examined. The numbers of patients were recorded as a percentage of the population visiting a general practitioner. Response to migraine prophylactic medications was regarded as supporting evidence of the diagnosis. Response was regarded as a complete resolution of symptoms.
Results: Of the 717 patients seen, 12 were identified as having probable or definite MV. Five patients were treated with migraine prophylactic medications, namely amitriptyline 25 mg nocte and / or sodium valproate CR 300 mg bd, and all showed a response to the treatment.
Conclusions: We conclude that the prevalence of MV as presenting complaint may be as high as 1.67%. This figure does however not reflect the total patient population that suffers from the condition - this figure may be much higher. Of those patients treated for MV the response was 100%, further supporting the diagnosis. MV is a relevant complaint that is often misdiagnosed as psychogenic in origin.

Background: Primary health care involves a sustained partnership between patients and providers that addresses the majority of a population's health needs over time. Patients' perception of satisfaction is an aspect of healthcare quality that is being increasingly recognised for its importance. The objective of this study was to investigate the factors contributing to patients' satisfaction with and their rating of the quality of care in Extension II Clinic in Gaborone, Botswana.

Method: This was a cross-sectional study in which 360 systematically selected participants completed five-point Likert scale self-administered questionnaires.
Results: Overall, participants were quite satisfied (mean score = 3.75) with the services provided by the different service providers. The participants indicated that overall, the quality of care of the health care facility was good (mean score = 3.45). The pharmacy received the highest satisfaction level with a mean rating of 4.1. Thirty-eight per cent of the participants rated the services provided by the doctors as best despite giving the highest quality ratings with a mean of 3.9 to the pharmacy compared to mean ratings of 3.4 for the doctors. The participants' greatest displeasure was with the time spent at the facility, as 63.9% of them were displeased with this aspect. A total of 36.9% was most pleased with information given to them as a factor of importance.
Conclusion: The participants were quite satisfied with the services provided as well as the quality of care provided by the different service providers of the health care facility. There is, however, a need for interventions in terms of time spent at the facility, which would promote good customer-focused service delivery.

Background: Highly active antiretroviral treatment (HAART) is essential in the treatment of HIV / AIDS; however, a holistic approach to HIV / AIDS management is important. This study was done to confirm the findings of two studies done previously in the eThekwini Metro of KwaZulu-Natal on private sector doctors' management of HIV-infected patients and to obtain more in-depth information about their non-pharmacological management of HIV-infected patients.

Methods: Two focus group discussions were conducted amongst private sector doctors in the eThekwini Metro, after obtaining their consent. The focus group sessions were scripted, audio-taped and transcribed verbatim. Prevalent themes were identified and reported.
Results: Eight doctors participated. Of the total patient population seen annually by the majority of the doctors, an average of 43.8% was HIV infected. Doctors in this study managed their patients both pharmacologically and non-pharmacologically. Seventy-five per cent of doctors indicated that the taste of medicine played an important role in non-adherence to treatment, but all agreed that cultural beliefs also influenced the patient's adherence to medication. Theft of medicines and the out-of-stock situation prevented antiretroviral drug access, which impacted negatively on adherence. Five doctors mentioned that depressed patients abused alcohol, resulting in non-adherence. One doctor reported that he used the biopsychosocial approach to improve adherence in his patients. Doctors indicated that the disability grant given by the South African Government caused patients not to adhere to treatment in order to maintain a CD4 count of 200 or less so as to qualify for the grant.
Conclusions: The study confirmed the previous study findings in that it showed that private sector doctors manage their HIV-infected patients both pharmacologically and non-pharmacologically. It further provided new and interesting information with regard to the non-pharmacological methods employed in HIV / AIDS management, that is the incorporation of cultural beliefs in the management of HIV-infected patients to improve adherence to treatment, and the role of the disability grant and pharmaceutical formulations in contributing to non-adherence by HIV-infected patients.

Background: Provision of surgical services at district hospitals (DHS) is cost effective and important. The District Hospital Service Package for South Africa (package of services) specifies the services that a district hospital should provide. The aim of this study was to document the surgical services provided at two DHS in KwaZulu-Natal and to compare this with the recommendations in the package of services.

Methods: In a retrospective quantitative study, data from 2008 were collected from the theatre register at two DHS. Data were analysed and results compared with the norms and standards in the package of services. Results were presented to staff at the hospitals, who then commented on the challenges of providing surgical services at DHS.
Results: Only 60% and 30% respectively of procedures listed in the package of services were being carried out at the two hospitals. In total, 3 900 procedures were carried out over the year. Dundee Hospital offered a broader range of surgical procedures and anaesthetics than the Church of Scotland Hospital (COSH). COSH has a large obstetric burden, with 3 666 deliveries each year. A large number of procedures were being carried out by a single operator.
Conclusions: Many surgical procedures are being carried out even though neither hospital provides the full complement of surgical services as specified in the package of services. The wide variation between the surgical services offered reflects the surgical and anaesthetic skills at the respective hospitals. Potential medico-legal hazards that require urgent attention were identified. A review of the package of services is essential to identify core procedures that must be provided at DHS.

Background: Trauma-related consultations, admissions and complications are the leading problems at Doctors on Call for Service (DOCS) Hospital, Goma, Democratic Republic of Congo, and yet no studies have been carried out to document the experience of long-stay traumatic-fracture patients in this hospital.

Aim: The aim of this study was to explore the experience and psychosocial needs of patients with traumatic fractures treated for more than six months at DOCS Hospital.
Methods: Six free-attitude interviews were conducted with purposively selected patients. The interviews were recorded with a tape recorder and transcribed verbatim, and content analysis was used to identify themes from the interviews.
Results: All patients could clearly connect the injury experience to severe pain that lingered on for weeks or months for some patients, accompanied by other symptoms such as insomnia, poor appetite and psychological symptoms. Most patients felt disabled, were abandoned by relatives or friends and experienced financial problems. Some benefited from the injury by way of strengthened marital links. Some patients complained of poor information about their illness and the management plan and did not appreciate the treatment from caregivers, while some disclosed their needs and expectations and appreciated the caregivers who showed interest in them.
Conclusions: The experience of long-term trauma has negative effects on the whole person of the patient, including his or her work and family, and some patients continue to suffer from the effects of the traumatic event up to six months later. The needs of patients suffering from trauma include reassurance by physicians and nurses, more information and participation in the decision-making process, regular visits from friends and family, and better bedside manners from caregivers.

My career in general practice started in the late 1960s as an assistant to two elderly GPs in a small village on Exmoor in North Devon, England. The doctor's names were Drs Mold and Nightingale, which sounded a bit like a television series, or one of those trade names for bespoke cosmetics or groceries.